TITLE PAGE
Title: HYPEROPIA: A META-ANALYSIS OF PREVALENCE AND A REVIEW OF
ASSOCIATED FACTORS AMONG SCHOOL-AGED CHILDREN
Authors and affiliations
1. Victor Delpizzo Castagno (VDC) (corresponding author)
Doctoral Program in Epidemiology, Federal University of Pelotas
Department of Specialized Medicine – Ophthalmology, Federal University of Pelotas
Rua Marechal Deodoro, 1160, Centro
96020-220 Pelotas, RS, Brazil
Correspondence to Victor Delpizzo Castagno (e-mail: [email protected]) –
Fone/Fax: (55)5333092400
2. Anaclaudia Gastal Fassa (AGF)
Doctoral Program in Epidemiology, Federal University of Pelotas
Department of Social Medicine
Rua Marechal Deodoro, 1160, Centro
96020-220 Pelotas, RS, Brazil
Correspondence to Anaclaudia Gastal Fassa (e-mail: [email protected])
Fone/Fax: (55)5333092400
3. Maria Laura Vidal Carret (MLVC)
Doctoral Program in Epidemiology, Federal University of Pelotas
Department of Social Medicine, Federal University of Pelotas
Avenida Duque de Caxias, 250, Fragata
96001-970 Pelotas, RS, Brazil
Correspondence to Maria Laura Vidal Carret (e-mail: [email protected])
Fone/Fax: (55)5333092400
4. Manuel Augusto Pereira Vilela (MAPV)
Postdoctoral Program in Epidemiology, Federal University of Pelotas
Department of Specialized Medicine – Ophthalmology, Federal University of Pelotas
Rua Marechal Deodoro, 1160, Centro
96020-220 Pelotas, RS, Brazil
Correspondence to Manuel Augusto Pereira Vilela (e-mail: [email protected])
5. Rodrigo Dalke Meucci (RDM)
Research Associate
Doctoral Program in Epidemiology, Federal University of Pelotas
Department of Social Medicine, Federal University of Pelotas
Avenida Duque de Caxias, 250, Fragata
96001-970 Pelotas, RS, Brazil
Correspondence to Rodrigo Dalke Meucci (e-mail: [email protected])
Abstract
Background: Studies show great variability on the prevalence of hyperopia among
children. This study aimed to synthesize the existing knowledge about hyperopia
prevalence and its associated factors in school children population, exploring the
reasons for this variability. Methods: This systematic review followed PRISMA
guideline. Searching several international databases, the review included population or
school based studies assessing hyperopia through cycloplegic autorefraction or
retinoscopy. A Meta-analysis on the prevalence of hyperopia was performed, following
the guidelines of MOOSE and using the random effects model. Results: The review
included 41 cross-sectional studies. The summary effect of hyperopia ranged from 8.4%
at age six, 2-3% from 9 to 14 years and about 1% at 15 years. Regarding associated
factors, age has an inverse association with hyperopia. The frequency of hyperopia is
higher among white children and those who live in rural areas. There is no consensus
about the association between hyperopia and gender, family income and parental
schooling. Conclusion: Future studies should use standardized methods to classify
hyperopia and enough sample size to evaluate age specific prevalence. Furthermore,
studies are required to refine the concept of hyperopic refractive error with evaluation of
accommodative and binocular functions and expand the frequency of assessment of
children to observe the evolution of emetropization to get a more accurate indication of
the groups of hyperopic children at risk of developing visual, academic and even
cognitive function sequelae.
Key words: Child; Cross-Sectional Studies; Hyperopia; Longitudinal Studies;
Prevalence
Background
Hyperopia in childhood, particularly when severe and/or associated with
accommodative and binocular dysfunctions may be a precursor of visual motor and
sensory sequelae.[1] Thus, children may present symptoms related to asthenopia while
reading or even changes such as accommodative esotropia and unilateral or bilateral
amblyopia.[2] Moreover, hyperopic children may present anisometropia if asymmetry
occurs during the process of emmetropization in the first years of life.[2] In fact, there is
no consensus about the role of hyperopia in stimulating emmetropization.[3] Some
studies suggest that hyperopic defocus is an essential mechanism for stimulating
emmetropization.[4-6]
Studies have also shown that axial length (AL) of the eye or the relation between
AL and corneal curvature (CC) radius plays an important role in the variability of
hyperopic spherical equivalent refraction (SE).[3-5, 7-9] Utermen observed that after
logistic regression, the combination of AL and CC contributed to explaining, on
average, 60.9% of variability in hyperopic SE among children aged 3 to 14 years.[9]
Although there are several studies on hyperopia, so far there has been no
systematic review on the subject. This systematic review aims to synthesize existing
knowledge about the prevalence of hyperopia among children and associated factors
and preceded a meta-analysis of hyperopia prevalence. This synthesis may help design
appropriate public policies to correct hyperopia in children.
Methods
Systematic Review
The literature search was performed on MEDLINE (PubMed), Scielo, Bireme,
Embase, Cochrane library, clinical trials registration website and WHO databases. The
following descriptors were used: refractive errors, hyperopia, prevalence and children,
limiting by keywords or words in the title or abstract, in isolated or combined form. The
searches were limited to the 0-18 years age range.
A total of 701 records were identified and screened (including theses, journals,
articles, books, book chapters and institutional reports) relating to hyperopia prevalence
in children up to 18 years old. 99 of these articles were duplicated. Population-based or
school-based studies assessing hyperopia through cycloplegic autorefraction or
retinoscopy were included. 525 papers were excluded owing to their focus on: specific
populations as well as publications about refractive errors in subjects with eye diseases
(amblyopia, strabismus, glaucoma, corneal abnormalities, chromatic aberrations,
accommodative and binocular dysfunction and asthenopia); other specific clinical
diseases or conditions (intellectual disability, cerebral palsy, dyslexia and prematurity);
ophthalmology/optometry outpatients; genetic and/or congenital alterations; before
and/or after examinations, clinical and/or surgical treatment; cost-benefit research and
geographically isolated populations. A further 44 articles were excluded due to: nonrandom sample of the general population and schools; determination of refractive error
without cycloplegia; cycloplegia only in children with low vision; hyperopia based only
on visual acuity testing, studies without specific cut-off for hyperopia, samples
excluding children that already were in eye care treatment, samples based on records of
clinics or mobile clinics, very small and stratified samples. 07 papers were included
from the selected articles (Figure 1).
Meta-analysis
Meta-analysis was undertaken regarding moderate hyperopia prevalence at
specific ages 6 to 15 year-old, based on 11 studies assessing moderate hyperopia taking
≥+2.00D as the cut-off point and a response rate greater than 80% (Table 1). The metaanalysis was performed using a Microsoft Excel.[10] Differences in the populations
studied, especially ethnicity, have a non-random impact on prevalence. The random
effects model was therefore used in order to obtain the summary effect and its
confidence interval. Heterogeneity was measured using the Q test and it was quantified
using I2 statistics expressed as a percentage.
This systematic review was performed according to the PRISMA[11] and
MOOSE[12] Statements and the Declaration of Helsinki guidelines.[13]
Results
•
Hyperopia prevalence by age in children
The review included 40 cross-sectional studies on prevalence and/or assessment
of risk factors for hyperopia. Eighteen studies were conducted in Asia, of which six
were carried out in China and five in India. The other Asian countries were: Nepal with
three studies, Malaysia with two, Cambodia and the Democratic Republic of Laos with
one study each. Seven studies are from Europe (two were conducted in the United
Kingdom; Poland and Sweden carried out two studies each and Finland one study). Six
studies are from the Middle East (Iran). Four studies were conducted in Australia, two
in the United States and one study each in South Africa, Chile and Mexico.
All samples of children used in the studies were population-based or schoolbased, except the study that used a sample of children from a private school in Xiamen,
China.[14]
In most studies, the cut-off point for hyperopia was based on the Refractive
Error Study in Children (RESC) protocol used in multicenter studies.[15] The spherical
equivalent refraction (SE) was: hyperopia ≥ +2.00D (one or both eyes, if none the eyes
are myopic). The studies used data from one or both eyes to determine prevalence.
However, some studies used different cut-off points[16-27], thus underestimating or
overestimating hyperopia prevalence compared to studies using the RESC protocol.
Some studies performed the examination in the right eye only, thereby
underestimating the prevalence of hyperopia.[17, 22] Out of a total of 22 articles on
hyperopia prevalence at specific ages (Table 1), three had losses of more than 20% and
six did not report their response rates.
The meta-analysis indicates that hyperopia prevalence decreases as age
increases, with a summary prevalence measure of 5% at age 7, 2-3% between age 9 and
14 and around 1% at age 15. Various studies on ages 6 to 8 presented large confidence
intervals.
The I2 indicates little heterogeneity among the studies for specific age,
however, the Forest Plot shows a tendency towards homogeneity among the studies,
especially from age of 9, as the age increases (Figure 2).
Fotouhi’s study was excluded because, despite meting the inclusion criteria, its
prevalence estimates were significantly different to all the other studies in various age
groups and thus was characterized as an outlier.[28]
In studies using the 5-15 age group and ≥+2.00 D (RESC) cut-off, hyperopia
prevalence ranged from 2.1% [29] to 19.3% [30, 31] (Table 1).
Although there is literature indicating a direct association between AL and age,
only a few studies have assessed its distribution by specific ages.[19, 32]
• Gender and hyperopia in children
Most studies showed no statistically significant association between gender and
hyperopia (Table 2).[18-20, 25-28, 31, 33-46] Regarding ocular components, girls
appear to have, on average, a shorter AL when compared to boys.[7, 32, 38, 47]
According to some studies, girls are more likely to be hyperopic when compared
to boys. In Australia, girls aged 6 are more likely to be hyperopic (15.5%) (95% CI
12.7-18.4) than boys of the same age (10.9%) (95% CI 8.5-13.2) (p = 0.005), although
this difference was not found among children aged 12 in the same study.[48] Similarly,
studies conducted in Chile, China and Nepal with children aged 5-15 years, showed that
girls are more likely to be hyperopic than boys: OR=1.21 (95% CI 1.03-1.43)[30],
OR=1.51 (95% CI 1.08-2.13)[49] and OR=1.44 (95% CI 1.02-2.03), [29] respectively.
However, in a study conducted in Poland, boys aged 6-18 years showed higher
hyperopia prevalence (40.3%) (95% CI 38.5-42.1) when compared to girls in the same
age range (35.3%) (95% CI 33.6 - 37.0).[22]
• Ethnicity and hyperopia in children
Some studies have shown that there is no significant difference in hyperopia
prevalence between Caucasian and Hispanic children [18] or between Caucasian and
Middle East children.[38, 48] There is also evidence that Caucasian children are more
hyperopic than African-American [16, 18, 40, 50], Black [51] and Asian (East and
South Asia) children. [38, 48, 51] With regard to specific ethnic groups, there is no
difference between hyperopia prevalence among Malay, Chinese and Indian
children[35], although Malaysian children are more hyperopic than Singaporean
(p=0.005)[52] and Melanesian children. [53] It was also found that children of other
ethnicities (not specified) are more likely to be hyperopic than Melanesian children
OR=3.72 (95%CI 1.34-10.3).[35] (Table 2)
In the South African study, hyperopia prevalence among children aged 7 years
was only 2.8%.[33] The majority of the South African population is Black, followed by
Asians (9.4%) and Caucasians (6.6%). In the Malay study, hyperopia prevalence among
children aged 10 years was 1.4%.[35] The ethnic composition of the region is mostly
Malay but approximately 28% of individuals have Chinese origin. The lowest hyperopia
prevalence (0.5%) was found in a study in Guangzhou, one of the most developed cities
in southern China.[34]
Regarding ocular components in different ethnicities, it was found that, on
average, AL is shorter and the CC is flatter among Caucasian children.[7, 38, 54]
• Parental education and socio-economic status and hyperopia in children
Most of the reviewed studies showed no significant association between parental
education and hyperopia in children (Table 2).[26, 33, 35, 37, 52, 55, 56] In an
Australian study, although there was no significant association between paternal
education and hyperopia among children under 6 years of age, maternal education
showed an inverse association with the presence of hyperopia among children aged 12
years (p=0.055) [48]. In a Chinese study the high level of parental education was a
protective factor against the presence of hyperopia among children aged 5-15 years,
OR=0.81 (95% CI 0.73 - 0.81).[34]
Regarding socio-economic status, maternal employment is directly related to
hyperopia in 6-year-old children in Australia (p=0.02), although it is not associated with
family income or paternal employment (p> 0.1).[48] In the same study, an association
between having both parents employed and hyperopia ≥ +2.00 D was found among 6year-old-children, after adjusting for gender, ethnicity and parental education (p=0.02) .
[48]
None of the three Indian studies with children aged 0-15 years, each one with
different cut-offs for hyperopia (≥+2.00D, ≥+1.00D and ≥+0.5 D), showed association
between socio-economic status (classified according to family income) and hyperopia.
[20, 26, 56]
In a study conducted in the United States children aged 6-72 months having
health insurance showed a greater chance of having hyperopia when compared to those
with no health insurance, OR=1.51 (95% CI 1.12 - 1.69).[50]
• Area of residence and hyperopia in children
There are few studies on the association between area of residence (urban or
rural) and hyperopia prevalence in children. In an Indian study, children aged 0-15 years
who lived in two rural areas were more likely to be hyperopic when compared to those
living in urban areas, OR=2.84 (95% CI 2.16-3.75) and OR=1.50 (95% CI 1.17-1.92)
respectively (Table 2).[26] In another study conducted in India with children aged 7-15
years, those aged 8, 9, 12 and 13 years living in rural areas presented higher prevalence
of hyperopia than those of the same age living in urban areas (Table 2).[44]
An Iranian study showed that children aged 7-15 years living in rural areas are
more likely to be hyperopic than those living in urban areas, OR=2.0 (95% CI 1.093.65)[28] and other study in Poland reported that children aged 6-18 years living in
urban areas showed lower frequency of hyperopia when compared to children living in
rural areas (p<0.001) (Table 2).[17]
Two reviewed articles (one conducted in China with children aged 6-7 years and
other in Cambodia with children aged 12- 14 years) showed no significant association
between area of residence and hyperopia. [14, 46] In the Cambodian study, hyperopia
prevalence rates among children living in urban area and rural area were 1.4% (95% CI
0.1 - 1.7) and 0.4% (95% CI 0.1 - 1.9) respectively (Table 2). [46]
• Outdoor activities and hyperopia in children
Rose et al. noted that children aged 6 and 12 years in Australia who spent more
time per week doing outdoor activities (outdoor sports, picnics and walking) were more
hyperopic than those who spent less time practicing these activities, adjusted for gender,
ethnicity, presence of myopia in parents, near activities, and maternal and paternal
education and working mothers (p=0.009 and p=0.0003, respectively) (Table 2).[5]
These authors also noted that there was a statistically significant trend toward greater
hyperopic spherical equivalent refraction as tertiles of outdoor activities increased and
tertiles of near activities decreased.[5] In the same study, Rose concluded that the
hyperopic spherical equivalent refraction was more common in children who dedicated
less time to near activities and more time to outdoor activities.[5]
Spending time engaged in outdoor activities was slightly associated with
hyperopia (β=0.03, p<0.0001) among 12-year-old-children in Australia. In our study,
we found that children who performed near activities (reported by parents), such as
reading (<30cm), were significantly associated with less hyperopia (p<0.0001), after
adjusting for age, gender, ethnicity and type of school (Table 2).[57]
In the United States, Mutti et al. examined 366 children with mean age of
13.7±0.5 years and showed (using the Wilcoxon rank-sum test) that myopic children
spend more time reading for pleasure (p=0.034) and less time playing sports (p=0.049)
compared with hyperopic children.[4]
Discussion
There are several studies on the prevalence of hyperopia in childhood, but a
great difficulty arises when attempting to compare them. This is partly due to the
methodological characteristics of each study. Regarding the diopter value, there is no
consensus on the cut-off point for diagnosing children as hyperopic, nor on what is the
most appropriate measure: a greater, or lesser, hyperopic corneal meridian or spherical
equivalent
refraction.[2]
However,
cycloplegia
followed
by
retinoscopy
or
autorefraction is the best way of testing to diagnose ametropias, although doubts remain
as to its accuracy in children with darker irises.[58] Most studies classify an individual
as being hyperopic after binocular examination, but others use the eyes separately as
unit sample or examine only one of the eyes (usually the right one) relying on evidence
of good correlation between ametropia in both eyes. [2]
The RESC protocol has been used as a way of standardizing the methodology
applied in studies on refractive errors, thus improving the comparability of results
between child populations. [15] Hyperopia has an inverse association with age, is more
common in Caucasian children and in those who live in rural areas or spend more time
doing outdoor activities and it shows inconsistent results regarding association with
gender, socio-economic status and parental education.
There is consistency among the studies about the inverse association between
hyperopia and age. Although emmetropization is minimal after the age of three,[3]
there are studies stating that slow growth in AL lasts until around the age of 12-14
years.[9, 32, 59] The larger confidence intervals among the ages 6 to 8 indicate a less
precise estimate of prevalence which is related to lower sample size in these specific
ages. However, it might also reflect greater difficulty in performing examinations in
younger children, or greater variability in different populations in this age range, such as
the heredity of refractive error or ocular characteristics of components such as axial
length among different ethnicities.
Although the studies included in the meta-analysis were selected due to its
methodological similarity and high response rate, some methodological variations may
still affect the summary effect estimation.
The conflicting results when assessing the association between gender and
hyperopia may be related to gender representativeness in the studies. On the one hand,
the gender ratio is fairly even, suggesting good representativeness. Yet in some cultures
girls have more difficulty in accessing schools, which could imply selection bias in
hyperopia prevalence. On the other hand, females have greater acceptance and
participation in studies, trials and interviews with scientific purposes that could lead to
positive selection bias.[31]
The particularly low hyperopia prevalence could be partly explained by
ethnicity, as in Durban, South Africa [33], where the majority of the population are
Black, followed by Asians. Regarding ocular components, axial length in both Africans
and Asians is longer than in Caucasian individuals.
Literature shows that populations with high prevalence rates of myopia generally
have low prevalence of hyperopia, as in China. [34, 38] This aspect may influence the
prevalence of hyperopia in places where there is a considerably high density of Chinese
ethnicity when compared to the native population, as in Durban and Gombak.[33, 35]
No association was found between parental education and socio-economic status
and hyperopia in children. As for ocular components, in the United States Lee observed
a statistically significant association (p<0.01) between years of education and larger AL
in individuals aged 43-84 years, indicating that this aspect should be better studied in
children.[60]
Some authors point to geographical factors as potential determinants of
ametropias, such as location and type of residence. The idea is that greater levels of
hyperopia may be found in people who live in rural areas and in houses, because they
do more outdoor activities.
The controversy as to the impact of environmental factors on hyperopic
spherical equivalent refraction in children still remains and most of the findings come
from studies where the main focus is on the relationship between these factors and the
onset of myopia. Near activities increase the demand of the accommodative process
(hyperopic defocus) stimulating changes in the dimensions of ocular components, such
as increases in AL, thus decreasing the eye’s chance of remaining hyperopic.[3]
On the other hand, children who spend more hours per week practicing outdoor
activities (including sports), do not require as much accommodation to practice these
activities. Thus, the stimulation of ocular growth decreases due to low accommodative
demand.[57, 59] The role of light intensity must also be considered. Since light is
usually of greater intensity outdoors, eye exposure results in a more constricted pupil,
increasing the depth of focus and leading to a less unfocused image.[5] In addition, the
dopamine released by light stimulus on the retina can contribute directly to inhibiting
ocular growth.[5, 61]
Conclusion
The large variability of hyperopia prevalence raises questions about the ability of
demographic, socio-economic and environmental factors to completely explain the
hyperopia causal chain. Future studies should refine the evaluation of these factors,
particularly the role of outdoor activities and ethnicity, as well as exploring other
potential risk factors such as heredity or diet. In order to improve the consistency of
analysis it is necessary to standardize refractive error measurement using the RESC
Protocol and to perform refractive examination using cycloplegia. It is also important to
have population-based or school-based representative samples, with low percentages of
loss to follow-up and large enough samples to stratify by specific age. More studies on
yougers than 9 years-old, with larger samples, are necessary to have a more precise
prevalence estimate.
AAO recommends the under correction of hyperopia, however despite the fact
that a large percentage of hyperopia appears to be benign at very early ages, an
important group might develop a sequelae. More studies are needed to refine the
concept of hyperopic refractive error with evaluation of accommodative and binocular
functions and increment of the frequency of children assessment to observe the
evolution of emetropization to get a more accurate indication of the hyperopic children
groups at risk of developing visual, academic and even cognitive function sequelae.[2]
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
VDC and AGF planed the study, conducted the data analysis and wrote the
paper. MLVC and MAPV contributed to the planning of the study and revising of the
paper. RDM conducted the data analysis and revising of the paper. All authors read and
approved the final manuscript.
Author details
1,4
Doctoral Program in Epidemiology, Federal University of Pelotas. Department of
Specialized Medicine – Ophthalmology, Federal University of Pelotas, RS - Brazil.
2,3,5
Doctoral Program in Epidemiology, Federal University of Pelotas. Department of
Social Medicine, Federal University of Pelotas, RS - Brazil.
Acknowledgements
This systematic review is funded by the Brazilian Federal Agency for the
Support and Evaluation of Graduate Education (CAPES) of the Ministry of Education,
Brazil.
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FIGURE LEGENDS
Figure 1. Flow of information through the different phases of the systematic review.
Figure 2. Fostes plots hyperopia prevalence by age: metha-analisis
Screening
99 duplicates
602 screened records
525 records were excluded
Eligibility
identification
701 records were identified through database
searching or other sources
77 full-text articles were
assessed for eligibility
44 full-text articles were
excluded
Included
07 papers found in the references of
selected papers
Figure 1
40 studies were included in
the quantitative synthesis
Figure 3
Table 1. Hyperopia prevalence among children in the analyzed studies
Author (Year)
Location
N
Age range
Zhao (2000) [49]
5884
5-15 years
Shunyi District, China
He (2004) [34]
Not available
86.4
4.6
4.4 – 4.9
7560
5-16 years
•+2.00 D
Right eye
ca
Not stated
4.0
Not available
Xiamen city: 132
Xiamen
countryside: 104
Singapore: 146
6-7 years
•+2.00 D
Right eye
ca
Not stated
Xiamen city: 3.0
Xiamen countryside: 1.9
Singapore: 2.7
0.8 – 7.8
1.4 – 2.3
0.8 – 6.9
Pi (2010) [36]
China
2.7
95% CI
•+2.00 D
RESC
ca
Hong Koong, China
Yong Chuan District, Western
95.9
Prevalence (%)
5-15 years
Fan (2004) [62]
Xiamen city, Xiamen
Countryside and Singapore,
China
•+2.00 D
RESC
ca
Response
Rate (%)
4364
Guangzhou, China
Zhan (2000) [14]
Hyperopia definition
SE
3070
6-15 years
•+2.00 D
At last one eye was
hyperopic
cr
88.50
3.26
2.6 – 3.9
Age specific prevalence (95% CI)
Males:
5 years: 8.8% (2.4 – 15.2)
15 years: less than 2%
Females:
5years: 19.6% (8.1 – 31.0)
15 years: less than 2%
5 years: 17.0% (12.8 – 21.3)
6 years: 10.7% ( 6.4 – 15.1)
7 years: 4.0% (1.3 – 6.7)
8 years: 7.1% (3.9 – 10.4)
9 years: 3.8 % (2.0 – 5.6)
10 years: 4.6% (2.1 – 7.1)
11 years: 3.5% (1.7 – 5.6)
12 years: 2.0% (0.5 – 3.6)
13 years: 3.4 % (1.6 – 5.2)
14 years: 1.2% (0.3 – 2.1)
15 years: 0.5% (0.0 – 1.3)
Not available
Not available
6 years: 9.21% (5.5 – 12.9)
7 years: 7.7% (4.7 – 10.6)
8 years: 5.3% (2.9 – 7.7)
9 years 3.1% (1.3 – 4.9)
10 years: 3.5% (1.6 – 5.5)
11 years: 1.2% (0.0 – 2.5)
12 years: 0.7% (0.0 – 1.6)
13 years: 0.3% (0.0 – 1.0)
14 years: 1.1% (0.0 – 2.2)
15 years: 0.9% (0.0 – 2.1)
He (2007) [63]
2454
12-18 years
Yangxi County, China
Saw (2006) [52]
Kuala Lumpur, Malaysia
Singapore
Goh (2005) [35]
Gombak District, Malaysia
Pokharel (2000) [29]
Mechi Zone, Nepal
Malaysia: 1752
Singapore:1962
7-9 years
• +2.00D
RESC
ca
97.6
83.3
1.20
0.8 – 1.6
Malaysia:2.9
1.9 – 3.8
Singapore: 1.7
1.2 – 2.4
4634
7-15 years
•+2.00 D
RESC
ca
83.8
1.6
1.1 – 2.1
5067
5-15 years
•+2.00 D
RESC
ca
Not stated
2.1
Not available
Gao (2012) [46]
Phnom Penhn and Kandal
•+2.00 D
RESC
ca
5527
12-14 years
Provinces, Cambodia
•+2.00 D
At last one eye was
hyperopic
cr
89.8
Urban: 1.4
0.1 – 1.7
Rural: 0.4
0.2 – 0.6
13 years: 0.9% (0.1 – 3.1)
14 years: 1.5 % (0.5 – 2.5)
15 years: 1.3 % (0.5 – 2.2)
16 years: 1.0% (0.3 – 2.5)
17 years: 0.0
Malaysia (N=1752)
7 years: 5.0% (3.0 – 7.0)
8 years: 2.0% (0.7 – 3.3)
9 years: 1.6% (0.4 – 2.8)
Singapore (N=1962)
7 years: 2.1% (1.3 – 3.3)
8 years: 1.9% (1.0 – 3.3)
9 years: 0.8% (0.2 – 2.1)
7 years: 5.0% (3.0 – 7.0)
8 years: 2.0% (0.7 – 3.3)
9 years: 1.6% (0.4 – 2.8)
10 years: 1.4 % (0.1 – 2.6)
11 years: 0.9 % (0.0 – 2.6)
12 years: 0.6% (0.0 – 1.2)
13 years: 0.5% (0.0 – 1.1)
14 years: 0.0
15 years: 0.9% (0.0 – 1.9)
Not available
Urban:
12 years: 0.7% (0.4 – 1.0)
13 years: 0.7% (0.4 – 0.9)
14 years: 0.8% (0.3 – 1.3)
6 years: 3.1% (1.7 – 5.1)
11years: 1.1% (0.3 – 2.9)
Casson (2012) [43]
Vientiane Province, Lao PDR
2899
6-11 years
•+2.00 D
RESC
cr
87.0
2.8
1.9 – 3.7
Murthy (2002) [55]
New Delhi, India
6447
5-15 years
Dandona (2002) [56]
Mahabubnagar, Andhra
4074
7-15 years
Pradesh, India
Uzma (2009) [44]
Urban: 1789
Hyderabad, India
Rural: 1525
7-15 years
•+2.00 D
RESC
cr
•+2.00 D
At last one eye was
hyperopic
cr
•+2.00 D
At last one eye was
hyperopic
ca
92
92.3
7.4
0.68
6.0 – 8.8
0.4 – 1.0
5 years: 15.6 % (11.0 – 20.2)
6 years: 13.0% (9.1 – 16.8)
7 years: 10.7% (7.0 – 14.2)
8 years: 8.5% (5.9 – 11.2)
9 years: 6.6% (3.7 – 9.5)
10 years: 5.2% (2.4 – 8.1)
11 years: 7.8% (4.7 – 10.8)
12 years: 5.0% (3.5 – 6.5)
13 years: 3.3% (1.7 – 4.9)
14 years: 4.4% (2.4 – 6.5)
15 years: 3.9% (2.1 – 5.7)
Rural:
7 years: 0.7% (0.0 – 1.2)
8 years: 0.3% (0.0 – 0.8)
9 years: 0.4% (0.0 – 1.0)
10 years: 1.2% (0.1 – 2.3)
11 years: 1.6% (0.4 – 2.8)
12 years: 0.8% (0.0 – 1.5)
13 years: 0.6% (0.0 – 1.4)
14 years: 0.3% (0.0 – 1.1)
15 years: 1.1% (0.0 – 2.6)
Urban:
7 years: 4.6% (2.6 – 6.6)
8 years: 2.0% (0.4 – 3.6)
9 years: 1.7% (0.8 – 2.6)
10 years: 1.3% (0.5 – 2.1)
11 years: 2.2% (0.9 – 3.1)
12 years: 0.4% (0.0 – 0.8)
13 years: 0.2% (0.0 – 0.4)
14 years: 0.0
15 years: 0.4% (0.0 – 0.8)
Not stated
Urban: 3.3
1.8 – 4.8
Rural: 3.1
1.7 – 4.5
Rural:
7 years: 9.8% (6.6 – 13.0)
8 years: 8.1% (5.4 – 10.8)
9 years: 7.3% ( 3.7 – 10.9)
10 years: 4.1% (2.1 – 6.1)
11 years: 3.2% (1.9 – 4.5)
12 years: 3.2% (1.6 – 4.8)
13 years: 2.4% (0.9 – 3.9)
14 years: 0.0
15 years: 0.0
Fotouhi (2007) [28]
Dezful, Iran
Hashemi (2010) [64]
Tehran, Iran
Ostadimoghaddam (2011) [31]
Mashhad, Iran
Rezvan (2012) [45]
Bojnourd, Iran
Yekta (2010) [37]
Shiraz, Iran
Robaei (2005) [65]
SMS, Sydney, Australia
Ip (2008) [48]
SMS, Sydney, Australia
7 years: 28.9% (22.6 – 35.2)
8 years: 22.7% (16.4 – 28.9)
9 years: 16.7% (12.0 – 21.4)
10 years: 12.4% (7.9 – 17.0)
11 years: 12.9% ( 8.3 – 17.5)
12 years: 16.9% (12.3 – 21.5)
13 years: 14.1% (10.6 – 17.6)
14 years: 13.0% (9.8 – 16.1)
15 years: 10.3% (1.5 – 19.1)
3673
7-15 years
•+2.00 D
RESC
ca
96.8
16.6
13.6 – 19.7
345
5-10 years
•+2.00 D
Right eye
ca
Not stated
10
Not available
Not available
639
5-15 years
•+2.00 D
At last one eye was
hyperopic
ca
Not stated
19.05
15.7 – 22.4
Not available
1551
6-17 years
•+2.00 D
RESC
ca
76.8
5.4
4.3 – 6.5
8 years: 6.8% (2.7–11.0)
9 years 8.2% (3.9–12.5)
10 years: 8.3% (4.1–12.6)
11 years: 5.6 % (2.0–9.2)
12 years: 3.8% (1.3–6.2)
13 years: 2.3% (0.3–4.3)
14 years: 2.5% (0.3–4.6)
7 years: 8.9% (6.1 – 11.8)
8 years: 7.7% (1.9 – 13.5)
9 years: 4.8% (1.6 – 8.1)
10 years: 7.0% (2.8 – 11.1)
11 years: 2.1% (0.7 – 5.8)
12 years: 3.0% (1.2 – 4.8)
13 years: 2.2% (0.6 – 3.8)
14 years: 5.9% (0.1 – 11.8)
15 years: 0.0
2130
7-15 years
•+2.00 D
RESC
ca
87.88
5.04
3.5 – 6.6
1765
6 years
•+2.00 D
Right eye
ca
Not stated
9.8
Not available
4094
6 years
12 years
•+2.00 D
Eye with greater
refractive error
ca
-
6 years: 13.0% (9.1 – 16.8)
12 years: 5.0% (3.5 – 6.5)
Not stated
-
-
Ip (2008) [38]
SMS, Sydney, Australia
Robaei (2006) [66]
SMS, Sydney, Australia
Grönlund (2006) [39]
Gothenburg, Sweden
Laatikainen (1980) [67]
Uusimaa County, Finland
O’Donoghue (2012) [41]
Northern Ireland (NICER)
Logan (2011) [51]
Birmingham, England (AES)
Naidoo (2003) [33]
Durban area, South Africa
2353
11-15 years
•+2.00 D
Both eyes
ca
Not stated
3.5
2.8 – 4.1
2353
12 years
•+2.00 D
Both eyes
ca
75.3
5
Not available
143
4-15 years
•+2.00 D
At last one eye was
hyperopic
ca
Not stated
9.1md
Not available
7-15 years
•+2.00 D
Right eye
cr
822
1053
596
4890
6-7 years
12-13 years
6-7 years
12-13 years
5-15 years
• +2.00D
RESC
ca
•+2.00 D
Either/both eyes
ca
•+2.00 D
RESC
ca
Not stated
62.0 in
children 67 years
65.0 in
children
12-13
years
Not stated
87.3
9.7
Not available
Not available
Not available
Not available
7 – 8 years: 19.1% (13.0 – 25.1)
9 – 10 years: 6.9% (3.5 – 10.3)
11 – 12 years: 11.7% (7.5 – 15.9)
14 – 15 years: 3.6% (1.1 – 6.1)
6-7 years: 26% (20-33)
12-13 years: 14.7% (9.9 – 19.4)
26
20 – 33
14,7
9.9 – 19.4
12.3
8.8–15.7
5.4
2.8 – 8.0
2.6
Not available
Not available
5 years: 2.7% (0.6 – 4.8)
6 years: 2.4% (0.7 – 4.1)
7 years: 2.8% (0.9 – 4.7)
8 years: 1.3% (0.1 – 2.6)
9 years 2.9% (0.1 – 5.7)
10 years: 3.4% (1.8 – 4.9)
11 years: 3.5% (1.9 – 5.1)
12 years: 3.2% (1.2 – 5.1)
13 years: 2.9% (0.3 – 5.5)
14 years: 1.9% (0.6 – 3.2)
15 years: 0.7% (0.0 – 1.8)
Maul (2000) [30]
La Florida, Chile
5303
Czepita (2008) [17]
Urban: 1200
Czeczecin, Poland
Rural:1006
Kleinstein (2003) [18]
CLEERE Study, USA
Zadnik (2003) [19]
CLEERE Study, USA
Dandona (1999) [20]
Andhra Pradesh, India
2523
5-15 years
•+2.00 D
RESC
ca
75.8
10-14 years
•+1.50 D
Right eye
cr
Not stated
5-17 years
•+1.25 D in each
meridian
Right eye
ca
2583
7-12 years
599
0-15 years
•+1.25 D§
Right eye
ca
•+1.00 D
Eye with higher
refractive error
cr
19.3
Not available
Urban: 7.1
5.6 – 8.5
Rural: 30.8
27.9 – 33.7
Not stated
12.8
11.5 – 14.1
Not stated
8.6
Not available
Not stated
41.14
24.9 – 58.0
Males:
5 years: 22.7% (18.0 – 27.4)
15 years: 7.1% (3.5 – 10.6)
Females:
5years: 26.3% (22.0 – 30.6)
15 years: 8.9% (3.7 – 14.1)
Urban (N=1200):
10 years: 8.3% (5.2 – 11.3)
11 years: 4.1% (1.6 – 6.6)
12 years: 9.9% (5.8 – 14.0)
13 years: 7.7% (4.3 – 11.1)
14 years:5.3% (2.2 – 8.3)
Rural (n=1006)
10 years: 33.3% (27.1 – 39.5)
11 years: 28.4% (22.1 – 34.7)
12 years: 26.9% (20.9 – 32.9)
13 years: 30.5% (24.4 – 36.5)
14 years:36.4% (28.7 – 44.1)
Not available
Not available
Not available
Shrestha (2011) [21]
2236
5-16 years
Jhapa, Nepal
Czepita (2007) [22]
Szczecin, Poland
Vilareal (2003) [23]
Monterrey, Mexico
•+1.00 D†
Either/both eyes
cr
Not stated
20,3
Not available
Not available
6 years: 36.5% (31.8 – 41.3)
7 years: 19.2% (15.4 – 22.9)
8 years: 17.4% (13.8 – 21.0)
9 years 11.3% (8.3 – 14.3)
10 years: 11.0% (8.0 – 14.0)
11 years: 10.9% (8.0 – 14.0)
12 years: 8.3% (5.6 – 10.9)
13 years: 11.8% (8.1 – 15.5)
14 years: 8.2% (5.3 – 11.2)
15 years: 8.6% (5.4 – 11.8)
16 years: 2.8% (0.6 – 5.1)
17 years: 2.5% (0.3 – 4.7)
18 years: 3.2% (0.7 – 5.7)
4422
6-18 years
•+1.00 D
Right eye
cr
Not stated
13.05
Not available
1035
12-13 years
•+1.00 D
Not stated
6
Not available
Not available
ca
Vilareal (2000) [24]
1045
12-13 years
•+1.00 D
Right eye
cr
Not stated
8.4%
Not available
Not available
412
5-15 years
•+0,50 D
Right eye
ca
Not stated
78.6
74.6 – 82.6
Not available
2603
0-15 years
Not stated
62.6
57.0 – 68.1
Not available
964
10-19 years
Not stated
1.24
Not available
Götemborg area Sweden
Hashemi (2004) [25]
Tehran, Iran
Dandona (2002) [26]
Andhra Pradesh, India
Niroula (2009) [27]
Pokhara, Nepal
•+0,50 D
Eye with higher
refractive error
cr
•+0,50 D‡
Both eyes
cr
Not available
y=years (age); CI: Confidence Interval; SE: mean spherical equivalent; RESC: The Refractive Error Study in Children; ca: cycloplegic autorefraction; cr: cycloplegic retinoscopy
† study did not mention SE in its definition of hyperopia
‡ It was considered +0,5 diopter or more spherical power
§ Define as +1.25 D or more in both meridians
Figure 4
Table 2. Hyperopia associated factors
Author (Year)
Location
Ip (2008) [48]
Sydney Myopia Study (SMS)
Australia
Ip (2008) [38]
Sydney Myopia Study (SMS)
Australia
Ip (2008) [57]
Sydney, Australia
Rose (2008) [5]
Sydney Myopia Study (SMS)
Australia
Maul (2000) [30]
La Florida, Chile
Zhao (2000) [49]
Shunyi, China
Zhan (2000) [14]
Xiamen city, Xiamen Countryside and
Singapore, China
He (2004) [34]
Guangzhou, China
Pi (2010) [36]
Yong Chuan District, Western China
Hyperopia associated factors
GENDER: Age 6, girls were more hyperopic 15.5% (95%CI 12.7 – 18.4) than boys 10.9% (95%CI
8.5 – 13.2) (p=0.005). Age 12, boys: 5.1% (95%CI 3.8–6.5), girls: 4.7% (95%CI 3.5–6.0), NS.
ETHNICITY: At age 6, more prevalent in European Caucasian 15.7% (95%CI 13.2–18.2) when
compared with East Asian 6.8% (95%CI 4.0–9.5) and South Asian 2.5% (95%CI 0.0–7.5). East
Asian, South Asian and Middle Eastern 8.4% (95%CI 1.6–15.2) do not present differences among
their prevalence. At age 12, more prevalent in European Caucasian, 6.4% (95%CI 5.2–7.7) than
East Asian 2.0% (95%CI 1.0–3.0). No difference between East Asian and Middle Eastern 7.4%
(95%CI 2.7–12.0) and European Caucasian and Middle Eastern.
PARENTAL EDUCATION: Age 12, Maternal Education, (p=0.055).
SOCIO-ECONOMIC STATUS: Age 6, Maternal Occupation, (p=0.02). Home Ownership or
Paternal Education or Employment (p>0.1), after adjusted for demographic factors (gender,
ethnicity, parental education, parental employment). Parental Employment was associated with
moderate hyperopia (+2.00 D), (p=0.02).
GENDER: Age 11-15, no difference among boys 3.6% (95%CI 2.6–4.7) and girls 3.3% (95% CI
2.2–4.4). Age 12, girls showed a lower mean spherical equivalent (SE) (+0.39D) than boys
(+0.58D), (p=0.04).
ETHNICITY: European Caucasian 4.4% (95%CI 3.6–5.3) are more likely to have moderate
hyperopia (+2.00 D) than East Asian 1.1% (95%CI 0.2–2.1), South Asian 0.0%(–) and other mixed
ethnicity 1.7% (95%CI 0.0–3.6). Middle Eastern 6.1% (95%CI 1.5–10.7) are more likely to have
moderate hyperopia than South Asian. There was no difference between European Caucasian and
Middle Eastern. Age 12, Middle East showed a lower mean of SE (+0.71) than Caucasian (+0.82D)
(p=0.03). Caucasian had the highest mean SE (+0.82D) when compared to all ethnicities together
(+0.04D), (p<0.0001).
OUTDOOR ACTIVITIES: Age 12, greater time, ( coefficient=0.03, p <0.0001), and weakly
correlated with near-work activities (r =0.1, p< 0.0001).
NEAR WORK ACTIVITIES: Parental Reports of Close Reading Distance (< 30 cm) (p < 0.0001),
after adjustment for age, sex, ethnicity, and school type.
OUTDOOR ACTIVITIES: Age 6 and 12, Greater Number of Hours, p = 0.009 and p= 0.0003
respectively, after adjustment for gender, ethnicity, parental myopia, near work, maternal and
parental education, and maternal employment.
NEAR WORK ACTIVITIES: Age 12, Greater Levels of Near-work Activity, p =0.8.
AGE: 5-15, inverse relation (p<0.05).
GENDER: Age 5-15, girls OR=1.21 (95% CI 1.03-1.43).
AGE: 5-15, inverse relation OR= 0.75 (95% CI 0.71-0.79).
GENDER: Age 5-15, girls OR=1.51 (95%CI 1.08-2.13).
RESIDENCE AREA: Age 6 -7, Residence Zone, p=0.50.
AGE: 5-15, inverse relation OR= 0.77 (95% CI 0.73-0.81).
GENDER: Age 5-15, NS p=0.233.
PARENTAL EDUCATION: inverse relation OR=0.81 (95%CI 0.66-0.98).
AGE: 6 – 15, inverse relation OR=0.831 (95%CI 0.728-0.948), p<0.01.
GENDER: Age 6-15, 2 =2.977, NS p=0.08.
Dandona (2002) [26]
Andhra Pradesh, India
Laatikainen (1980) [67]
Uusimaa County, Finland
Grönlund (2006) [39]
Gothenburg, Sweden
AGE: 0 – 5, were more hyperopic than those 10 – 15, OR= 3.34 (95%CI 2.69–4.14), p<0.05. and 6
– 9 were more hyperopic than 10 – 15, OR=1.72 (95%CI 1.41–2.10), p<0.05
GENDER: Age 0-15 OR:1.19 (95%CI 0.76 – 1.86), NS.
SOCIO-ECONOMIC STATUS: Base Group: extreme lower income, Upper OR=2.27% (95%CI 0.59
– 8.77), Middle OR=2.21% (95%CI 0.89 – 5.50), Lower OR=1.76% (95%CI 0.74 – 4.19).
RESIDENCE AREA: Two Rural Areas, OR=2.84 (95%CI 2.16-3.75) and OR=1.50 (95%CI 1.171.92) when compared with Urban.
AGE: 7-15 years, inverse relation, x2=28.617, p<0.0005.
AGE: 4 – 15, Correlation SE OD: r= -0.37, p < 0.0001 and SE OS: R= -0.33, p < 0.0001.
GENDER: Age 4-15, SE OD (p= 0.61) and SE OS: (p=0.85).
OBS: The mean and standard deviation (SD) of the spherical equivalent (SE) was used in this study.
Dandona (2002) [56]
Andhra Pradesh, India
Dandona (1999) [20]
Andhra Pradesh, India
Murthy (2002) [55]
New Delhi, India
Hashemi (2004) [25]
Tehran, Iran
Fotouhi (2007) [28]
Dezful, Iran
Yekta (2010) [37]
Shiraz, Iran
Ostadimoghaddam (2011) [31]
Mashhad, Iran
Goh (2005) [35]
Gombak District, Malaysia
Varma (2009) [40]
Multi-Ethnic Pediatric Eye Disease Study
(MEPEDS)
Los Angeles County, California
USA
Multi-Ethnic Pediatric Eye Disease Study
Group (MEPEDS) (2009)
AGE: 7 -15, NS.
GENDER: Age 7-15, NS.
PARENTAL EDUCATION: Education of the father (grade level achievement: none, 1-5, 6-12, 1315, 15 or more), NS.
SOCIO-ECONOMIC STATUS: Extreme Lower, Lower, Middle, Upper, NS.
AGE: 0 – 15, NS.
GENDER: Age 0-15, NS.
SOCIO-ECONOMIC STATUS: Extreme Lower, Lower, Middle, Upper, NS.
GENDER: Age 11-13, girls OR=1.72 (95% CI 1.05-2.81).
PARENTAL EDUCATION: Age 11-13, Child Education, inversely associated OR=0.89 (95%CI
0.81-0.99).
AGE 5-15, inverse association, S p<0.001.
GENDER: Age 5-15, Boys, 78.6% (95%CI 74.6 – 82.6), Girls, 73.2 (95%CI 68.5 – 77.9), NS.
AGE 7-15, inverse relation OR= 1.73 (95%CI 0.83-0.94), p<0.001.
GENDER: Age 7-15, boys 16.1% (95% CI 11.0–21.1), girls 16.1% (95%CI 11.0–21.1), NS.
RESIDENCE AREA: Rural, OR=2.0 (95%CI 1.09-3.65).
AGE: 7-15, inverse relation OR=0.84 (95%CI 0.73-0.97), S, p=0.021.
GENDER: Age 7-15, boys: 5.17% (95%CI 3.19–7.15), girls, 4.90% (95%CI 2.32–7.48), NS,
p=0.863.
AGE: 5 – 15 inverse relation, S, (p < 0.001).
GENDER: Age 5-15, NS, p = 0.724.
AGE: 7-15, inverse relation OR= 0.72 (95%CI 0.62-0.82).
GENDER: Age 7-15, boys, 1.7% (95%CI 1.1–2.3), girls, 1.4% (95%CI 0.8–2.1).
ETHNICITY: Age 7-15, “other” ethnicities were more hyperopic OR=3.72 (95%CI 1.34-10.35) than
Malaysian and Chinese. No differences were found among Malaysian 1.5% (95%CI 1.1–1.9),
Chinese 1.1% (95%CI 0.4–1.7) or Indian 2.0% (95%CI 0.1–3.9).
PARENTAL EDUCATION: Parental with highest level of schooling, NS.
AGE: 6 – 72 months, Hispanic children, inverse relation, (6-11 months) vs (60-72 months)
OR=1.46 (95%CI 1.08–1.98) (P=0.0017). Age 6-72 months, African-American, NS.
ETHNICITY: Age 6-72 months, Hispanic were more hyperopic 27.1% (95%CI 24.0 – 30.1) than
African-American 21.1% (95%CI 17.9 – 24.3), after controlling for age, S, p<0.001. Age 6-11
months and 36-47 months Hispanic are more hyperopic 35.1% (95%CI 29.7 – 40.5) and 29.9%
(95%CI 26.0 – 33.8) than African-American, 18.1% (95%CI 13.5 – 22.7) and 20.7% (95%CI 17.3 –
24.1) respectively.
Pokharel (2000) [29]
Mechi Zone, Nepal
Czepita (2007) [22]
Czeczecin, Poland
Naidoo (2003) [33]
Durban area, South Africa
Garner (1990) [53]
Kleinstein (2003) [18]
Zadnik (2003) [19]
Giordano (2009) [16]
Island of Efaté, Republic of Vanatu, Melanesia
Kuala Lumpur, Malaysia
Collaborative Longitudinal Evaluation of
Ethnicity and Refractive Error Study Group
(CLEERE) Study
Eutaw, Alabama; Irvine, California and
Houston, Texas
USA
Collaborative Longitudinal Evaluation of
Ethnicity and Refractive Error Study Group
(CLEERE) Study
Eutaw, Alabama; Irvine and Orinda, California
and Houston, Texas
USA
Baltimore Pediatric Eye Disease Study
(BPEDS)
USA
AGE: 5 – 15, as continuous variable, NS.
GENDER: Age 5-15, girls OR=1.44 (95%CI 1.02-2.03).
AGE 6-18, negative correlation, Sr=0.907, S, p<0.001
GENDER: Age 6-18, boys 40.3%(95% CI 38.5 – 42.1) are more hyperopic than girls, 35.3%
(95%CI 33.6 – 37.0).
AGE: 5 – 15 years, NS.
GENDER: Age 5-15, NS.
PARENTAL EDUCATION: parent with the highest education (grade level achievement: none, 1-5,
6-12, 13-15, 15 or more), NS.
AGE: 6 – 17, age groups Melanesian, NS.
ETHNICITY: Age 6, Malaysian were more hyperopic than Melanesian.
ETHNICITY: Age 5 – 17, white are more hyperopic 19.3% (95%CI 16.9 – 21.7) than Asians 6.3%
(95%CI 4.1 – 8.4) and African-Americans 6.4% (95%CI 4.3 – 8.5), x2=236.15, S, p<0.001. Age 517 white didn’t differ from Hispanics 12.7% (95% CI 9.7 – 15.7), NS, p=0.48. Age 5-17 Asians and
Africa-Americans, NS, p=0.07.
GENDER: Age 5-17, boys 12.6% (95%CI 10.8 – 14.4) are more hyperopic than girls 13.1% (95%CI
11.2 – 15.0).
AGE: Age 6 to 7 and age 8 were more hyperopic than 9 to14, S, p<0.0001.
ETHNICITY: 6 – 72 months, white are more hyperopic (+1.00) than African-American OR=1.62
(95%CI 1.51-1.74). White, 6 – 11: 33.0% (95%CI 22.9 – 43.1), 12 – 23: 30.3% (95%CI 23.5 –
37.1), 36 – 47: 27.5% (95%CI 21.5 – 33.5), 48 – 59: 33.3% (95%CI 26.8 – 39.9) and 60 – 72:
31.5% (95%CI 24.5 – 38.4) months are more hyperopic (+2.00D) than African American at same
age ranges, 21.2% (95%CI 12.4 – 30.0, 15.7% (95%CI 10.5 – 20.9), 16.2% (95%CI 11.5 – 20.9),
17.2% (95%CI 12.6 – 21.8) and 17.4% (95%CI 12.6 – 22.1) respectively.
AGE: 6 – 72 months. Those 12 – 23 months and 24 – 35 months are more hyperopic than 60 – 72
months OR=0.81(95%CI 0.68 – 0.97) and OR=0.74 (95%CI 0.62 – 0.88) respectively.
ETHNICITY: Age 6-72 months, Non-Hispanic white, children are more hyperopic than AfricanAmerican OR=1.63 (95%CI 1.43 – 1.87). Age 6-72 months, Hispanic white are more hyperopic
than African-American OR=1.49 (95%CI 1.32 – 1.68).
SOCIO-ECONOMIC STATUS: Age 6-72 months with Health insurance, OR=1.51 (95%CI 1.12 –
1.69).
Borchert (2011) [50]
Baltimore Pediatric Eye Disease Study
(BPEDS)
USA
O’Donoghue (2012) [41]
Northern Ireland Childhood Errors of
Refraction
(NICER)
Northern Ireland
AGE: 6 – 7 are more hyperopic 26% (95%CI 20 - 33) than 12 – 13 years, 14.7% (95%CI 9.9 19.4), p<0.005.
GENDER: Age 6-7, NS. Age 13-13, S.
Dirani (2010) [42]
The Strabismus, Amlyopia and Refractive
Errors in Singaporean children
(STARS)
Singapura
AGE: 6 – 72 months, inverse relation, Age 6 – 11.9 months 15.7% (95%CI 10.6 – 22.2), Age 24 –
35.9 months 6.8% (95%CI 4.6 – 9.6), Age 36 – 47.9 months 5.1% (95%CI 3.3 – 7.3) and age 60 –
72 months 5.7% (95% CI 3.8 – 8.0), S, p trend=0.001.
GENDER: Age 6-72 months, boys 6.6% (95%CI 5.1 – 7.7), girls: 9.4% (95%CI 7.9 – 11.1), NS,
p=0.75.
Casson (2012) [43]
Vientiane Province, Lao PDR
Uzma (2009) [44]
Hyderabad, Índia
Rezvan (2012) [45]
Bojnourd, Iran
Saw (2006) [52]
Gombak District, Kuala Lumpur
Malaysia
Singapore
GENDER: 6 – 11, NS, p=0.95.
GENDER: 7 – 15, Urban, boys 1.5% (95%CI 0.7–2.3), girls, 1.4% (95%CI 0.6–2.2). Rural, boys,
2.7% (95%CI 1.3–4.1), girls, 2.1% (95%CI 0.9–3.3), NS.
RESIDENCE AREA: Age 8, 9, 12 and 13, Rural, are more hyperopic than urban, 8.1% (95%CI
5.4–10.8) v 2.0% (95%CI 0.4–3.6), 7.3% (95%CI 3.7–10.9) v 1.7% (95%CI 0.8–2.6), 3.2% (95%CI
1.6–4.8) v 0.4% (95%CI 0.0–0.8) and 2.4% (95%CI 0.9–3.9) v 0.2% (95%CI 0.0–0.4), respectively.
AGE: 6 – 17, inverse relation, S, p < 0.0001.
GENDER: Age 6-17, boys, 4.4% (95%CI 2.8–5.9), girls, 6.1% (95%CI 4.5–7.7), NS.
AGE: 7, Malaysian are more hyperopic (5%) than Singapore (2.1%), Prevalence difference, -22.9%
(95%CI -24.8 to -20.9), S, p<0.001.
GENDER: Age 7-9, Malaysian boys are more hyperopic (3.2%) than Singaporean boys (1.3%),
Prevalence difference, -21.9% (95%CI -23.3 to -20.6), p<0.001.
ETHNICITY: Age 7-9, Singaporean, are less hyperopic (1.7%) than Malaysian (2.9%), Prevalence
difference, -21.1% (95%CI -22.1 to -20.2), p=0.005.
PARENTAL EDUCATION: Age 7-9, Completed Education Level of the Father, NS.
OBS: Differences in the prevalence rates of hyperopia between Malaysia and Singapore were considered
significant if the 95% confidence intervals of the differences in the prevalence rates did not cross zero and
p values were <0.05.
Logan (2011) [51]
Birmingham, England (AES)
Czepita (2008) [17]
Szeczecin, Poland
Gao (2012) [46]
Phnom Penhn, Cambodia
ETHNICITY: Age 6 -7, White European are more hyperopic, 22.9% (95%CI 12.9% – 32.8%) than
South Asian 10.3% (95%CI 6.2% - 14.4%) and Black African Caribbean 9.1% (95%CI 0.5 – 17.7).
South Asian v Black African Caribbean, NS. Age 12 – 13, White European 10.4% (95%CI 4.8% –
16.1%) v South Asian 2.6% (95%CI 0.0 - 5.6%), NS.
RESIDENCE AREA: Age 6-18, living in the city, are less hyperopic than those in the countryside,
S, p < 0.001.
AGE: 12, 13 and 14, Prevalence Rates, 0.7% (95%CI 0.4–1.0), 0.7% (95%CI 0.4–0.9) and 0.8%
(95%CI 0.3–1.3) respectively, NS.
GENDER: Age 12-14, boys: 0.6% (95%CI 0.3–0.8), girls, 0.9% (95%CI 0.6–1.1), NS.
RESIDENCE AREA: Age 12-14, urban, 1.4% (95%CI 0.1–1.7) v rural, 0.4% (95%CI 0.2–0.6),
NS.
Pokhara, Nepal
GENDER: 10 – 19, boys, 1.48% (95%CI 0.3–2.6), girls, 1.02% (95%CI 0.1–1.9), NS.
Niroula (2009) [27]
OR: odds ratio; CI: confidence interval; SE: spherical equivalence; NS: non-significant; S: significant